Fillable APPLICATION for ADMISSION (Asnuntuck Community College)

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APPLICATION for ADMISSION (Asnuntuck Community College)

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File type: PDF

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Fall (Aug-Dec)
Spring (Jan-May)
Winter (Dec-Jan)
Summer (May- Aug)
FOR OFFICE USE ONLY
Received Date _____/_____/________
BANNER @ __ __ __ __ __ __ __ __
Admit Type ____________________
Student Type ___________________
Entered By ____________________
Entered Date_____/_____/________
Application Fee Paid Yes No
Cash _________ Check #______________
Money Order_________ Waived__________
Credit/Debit Card
___________________________
Exp. Date _____/_______
APPLICATION for ADMISSION
(Please print legibly in blue or black ink)
Asnuntuck Community College
Yes
No
White (10)
Black or African American (20)
Asian (45)
American Indian or Alaskan Native (50)
Native Hawaiian or Other Pacific Islander (80)
Do you consider yourself to be Hispanic/Latino?
What is your race? (Select one or more)
This information is requested on a voluntary basis by the U.S. Department of Education, National
Center for Education Statistics. Your answer will not aect admission to or registration in the college.
ETHNICITY/RACE
Neither attended college
One or both attended college but did not earn a degree
One or both earned an associate degree
One or both earned a bachelor’s degree or higher
Check the category that applies to your parent(s) or guardian(s):
FAMILY EDUCATIONAL BACKGROUND
If no, are you a permanent resident? (green card holder) Are you a United States citizen?
CITIZENSHIP
Yes
No
M
F
Yes
No
Are you currently on active duty with the U.S. Armed Forces?
Are you currently a member of the National Guard or Reserve?
Have you ever served in the U.S. Armed Forces?
Are you a dependent of a member of the U.S. Armed Forces?
If you answered “Yes” to any of these questions, you may be entitled to benefits and should meet with
the college’s Veterans Certifying Oicial (VCO).
MILITARY STATUS
No
No
No
No
Yes
Yes
Yes
Yes
(ACTD)
(NGRE)
(VET1)
(VETD)
1. Are you eligible for in-state tuition because you have continuously resided in
Connecticut for at least one year and Connecticut is your permanent home?
2. If “No,” can you claim and demonstrate through documentation that you are
eligible for in-state tuition?
3. Check here if applying under the New England Regional Student program (NEBHE).
Out-of-state students may be eligible for a reduced tuition rate through the NEBHE program. For
details, see the college catalog or website.
If you answered “Yes” to question #2 or checked question #3, you must submit a “Declaration of
Eligibility for In-State or NEBHE Tuition” for review and determination of eligibility.
IN-STATE TUITION
Yes
No
Yes
No
NEBHE
Have you previously attended a CT Community College?
Have you previously attended this college?
Are you transferring from another college?
Yes
No
Yes
No
Yes
No
For which semester
are you applying?
Summer continuing into fall
ATTENDANCE & APPLYING
CONTACT INFORMATION
If yes, where?
Year
If yes, when?
Number & Street Apt. # City State Zip
Number & Street Apt. #
City
State Zip
Cell Phone Home Phone Work Phone
Mailing
Address
Permanent
Address
Phone
Numbers
(MM) (DD) (Year)
(
) - ( ) - ( ) -
Legal Last Name Legal First Name Middle Previous Maiden/Last Name
Social Security Number Date of Birth Gender
Email
(Social security number requested for purposes of financial aid, federal income tax benefits, provision of
some college services, accuracy of student records and other business purposes.)
IGNORE THIS SECTION
COLLEGE CAREER PATHWAYS APPLICATION
✔
College/University Name State
Dates of Attendance Graduation Date Degree Awarded
College/University Name State
Dates of Attendance Graduation Date Degree Awarded
College/University Name State
Dates of Attendance Graduation Date Degree Awarded
Signature
Signature
Email Communications
I request the college forward me any initial correspondence to the email address I have provided,
including personally identifiable information pertaining to me from college records protected by FERPA.
Consent for the Disclosure of Education Records
I understand that to maintain accurate student records, including the records pertaining to my
attendance at the college, and for other necessary business purposes, the college may need to
release or provide access to personally identifiable information in its records pertaining to me
to another college in the CT Community College System or to the system’s administrative oice.
Accordingly, I hereby authorize the college to release or allow access to such information to those
indicated for the purposes described.
I certify with my signature below that I am the applicant and that the information I have provided
above is accurate. If admitted, I pledge to comply in good faith with all the rules and regulations
of the college. I realize that any misleading information provided by me on this application may
be cause for dismissal. I understand that information collected in this application is for reporting
purposes only and will not be used in the selection process for admission.
INTENDED PROGRAM OF STUDY
In which degree/certificate program do you plan to enroll? (use attached list)
HIGHEST EDUCATIONAL LEVEL ACHIEVED
No high school diploma or GED (01)
High school diploma or GED (02)
Some college (06)
Undergraduate certificate (05)
Associate degree (07)
Bachelor’s degree (08)
Master’s degree (09)
Other advanced degree (10)
Doctoral degree (11)
First professional degree (JD, MD, DDS, LLB) (12)
Sixth-Year certificate (13)
Check only one
EDUCATIONAL GOAL
Developmental (college prep) education (DV)
English skills (ESL) (ES)
Certificate - undergrad credit (CT)
Fulfill other college’s requirement (AC)
Transfer without an associate degree (DN)
Associate degree (DG)
Earn associate degree, then transfer (DT)
Personal development course(s) (PD)
Job preparation/retraining course (JB)
Job promotion (JP)
Unsure at this time (UN)
Goal not listed (NL)
Check only one
ACADEMIC BACKGROUND
Yes
No
Pending
Yes
No
Yes
No
Yes
No
Yes
No
Do you have a high school diploma?
Have you passed the high school equivalency exam GED, TASC, HiSET?
(070997)
Are you a home school graduate? (I00001)
Have you participated in the High
School Partnership Program through
the CT Community Colleges?
Have you taken courses at your high
school and earned college credit?
(concurrent enrollment)
Please submit a copy of your final oicial high school transcript or equivalency credential.
PREVIOUS COLLEGES ATTENDED
COMMUNICATION & CONSENT
NOTICE OF NON-DISCRIMINATION
Notice of Non-discrimination: Asnuntuck Community College does not discriminate on
the basis of race, color, religious creed, age, sex, national origin, marital status, ancestry,
present or past history of mental disorder, learning disability or physical disability, sexual
orientation, gender identity and expression or genetic information in its programs and
activities. In addition, the College does not discriminate in employment on the basis of
veteran status or criminal record. The following individuals have been designated to
handle inquiries regarding the non-discrimination policies: Timothy St. James, Interim
Dean of Students/Title IX Deputy, tstjames@asnuntuck.edu (860) 253-3011 and Deborah
Kosior, 504/ADA Coordinator, AS-DisabilityServices@asnuntuck.edu (860) 253-3005,
Asnuntuck Community College, 170 Elm Street, Enfield, CT 06082.
Year Town/State
Grad Year Town/State
Primary Major Code
Secondary Major (optional) Code
Signature Date
Parent/Guardian Signature (if under 18) Date
Name of High School Graduation Year
City/State Country
IGNORE THIS SECTION
IGNORE THIS SECTION
IGNORE THIS SECTION
✔
✔
✔
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APPLICATION for ADMISSION (Asnuntuck Community College)

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Completed 3 February 2021

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